Flying surgeons

Friday 11pm

Friday 11pm

24 hours ago I was in Bangui winding down from operating on the 60 year old woman with a bowel obstruction. She turned out to have a sigmoid volvulus, not an uncommon problem. When a piece of the colon is longer than usual, it can twist around on itself blocking the intestine and eventually cutting off its own blood supply. We needed to remove a piece of her colon and give her a temporary colostomy. Some other MSF surgeon will hopefully reconnect her colon in 3 to 6 months from now.

Tonight I’m lying in bed in the town of Carnot, halfway between Bangui and the border with Cameroon. If you have been following the news about the CAR you may recognize Carnot as a place where a large number of people trying to travel to Cameroon had taken refuge in a Catholic church in mid- February.

This morning on rounds our team medical chief told me that there were a large number of patients at the hospital in Carnot needing emergency surgery after a sudden burst of violence earlier around dawn today. The decision had been made to send over a “flying surgery team” made up of me, C. who is one of the nurse anesthetists and T. who is one of the OR nurses. I had 15 minutes to pack a bag.

By the time our International Committee of the Red Cross (ICRC) plane left the runway in Bangui around noon, I had a little more information. We were taking with us boxes of supplies that had been previously packed in anticipation of this type of situation. We were taking everything you would need to do surgery including laryngoscopes, drugs, linen and disposables, an OR lamp, and multiple instrument trays including 1 traction set-up, 2 orthopedic sets to place external fixators, 1 amputation set, 2 “major” sets for laparotomies and a larger number of “minor” sets containing a handful of instruments to do small procedures. Our job was to go to Carnot and evaluate the patients. The plane would wait on the ground in Carnot and we would send back the sickest patients for surgery in Bangui. There would only be room on the plane for three patients on stretchers, one sitting up. Dr. D, one of the local MSF internists at our hospital would fly with us and return with the patients to provide any needed medical care during the flight. There were going to be more than four patients so we would need to decide if we should operate on the remaining injured in Carnot or ask for another plane the next day to evacuate more patients to Bangui. Just before we boarded in Bangui, I was told the plane needed to leave Carnot by 3PM for security reasons so we would need to work fast. The cherry on the sundae.

The airstrip at Carnot is a single dirt runway with a clearing at the far end for loading and turning the plane around. Our team left the airstrip at 1:15 in one MSF Landcruiser while the local MSF team unloaded our supplies in two others. The pilot, a young man with a South African accent and Tom Cruise/Maverick in Top Gun vibe (except more likeable, less cocky) assured us he would wait and wished us luck. 20 minutes later we were at the hospital, leaving us 65 minutes to do our job and get the patients for transfer loaded up for the 20 minute ride back.

The hospital in Carnot is a compound of at least 8 building. The emergency room with six beds in front, three in back and what looked to be an outpatient registration area and pharmacy was in the central building where a tremendous crowd of people moved about on the steps, spilling out of the rooms into the hallways. It was impossible to say who was a patient seeking care, who were family or friends of a patient and who was an onlooker. One of the nurses immediately led us to the back of the building to see the patients, shooing people out of our way until we arrived at the beds the back area, a dark corner of the interior sheltered from the elements but also from the light. Given that there was no electricity in the building (the first of a number of serial disappointments) it was a better place to play hide and seek than to examine patients.

There were three men on beds in the corners and the nurse began telling us about the first one, a man with his left lower leg in a posterior splint and circular bandage. Despite not having a x-ray (disappointment 2, the x-ray machine had not been working for some time and none of our patients today had any x-rays), he reportedly had an obvious open tib-fib fracture from a gunshot wound that morning.

I asked for some gloves, scissors and bandages to take down the dressing and examine him and met disappointment 3; the sudden influx of injured patients had depleted there dressing stores on hand and there was nothing readily available that would let me take down the dressings, examine the wounds and re-dress them within our time frame. We had carried our stethoscopes and our anesthetist C., had brought a box of gloves and some IV catheters, fluids and medications but we had assumed that basic dressings would be available at the hospital. All our dressing supplies were still boxed up in the other vehicles. I would need to leave the dressings intact and make decisions based on history and a limited exam.

The next hour was a cluster foxtrot. We asked more than once how many patients they had for us to evaluate overall and the answer was always the same….”more”. They showed us the 3 patients in the back then 2 more in the front rooms, all of whom needed operations, some sooner than later. C. stayed with those 5 to make sure they all had IVs, IV fluid, antibiotics and pain meds as needed while I followed the head of the hospital to another building to see more patients, all the time prioritizing the injuries in my head. Who has a potentially life threatening injury? Is anyone unstable for transfer? Who needs surgery within the next 24 hours and who can wait a day or two?

I usually think of patients as people with problems rather than simply by their medical problem but not right now. Mr. Gunshot Wound to the lower left chest and upper abdomen has stable vital signs, has equal breath sounds on the left and right plus mild but definite peritonitis on exam.  As long as his vitals stay OK he is number one on the plane with chest x-ray and laparotomy as soon as he arrives in Bangui. Should I put a chest tube in him before we send him? Still walking after the director I consider the four patients with open fractures from their gunshot wounds, Mr. Open Tib-fib fracture, Mr. Open Femur fracture and Mr. Open Femur fracture with an open ankle fracture and Mr. Open Humerus fracture with a non-viable hand from arterial injury. All need surgery but as long as they are well washed out, there is a window of several days before we need to put on an external fixator. The two with femur fractures seemed more acute to me; you can bleed a lot more into a femur compared to a foreleg fracture plus it’s more difficult to maintain any kind of reduction and pain control. There seems to be no rush for Mr. Open Humerus as we won’t be able to save his arm plus his hemoglobin was very low; he should get a blood transfusion before anyone operates. The pair of femur fractures will go today. That’s our three on stretchers…unless they have someone sicker.

Luckily they didn’t. In the next 20 minutes I met:

  1. An older man who had just arrived with a gunshot wound from earlier that morning. It had amputated his right thumb and crossed over to fracture both bones in his left forearm. His homemade dressings and splint were still intact but his left hand was cool to the touch, lacking all movement and sensation
  2. A 30 year old man with a through and through gunshot to his left hand from this morning.
  3. A man with a one week old open fracture of his right forearm from a machete attack. He had multiple other lacerations on his hands, chest and scalp which were all healing slowly without signs of infection.
  4. A man with a 3 day old through and through gunshot wound to the foot just below the ankle, clinically an open fracture but no exposed bone.
  5. A young man who 8 day earlier had been shot with the bullet entering high on the left hip at what is called the anterior iliac spine and entering the abdomen. The medical director told me with obvious (and deserved) pride that he had performed a laparotomy and resected a piece of the colon with an anastomosis, not an easy thing for someone with little formal surgical training beyond cesarean section. The colon had healed but the young man still had intolerable pain at the entrance site of the bullet. I didn’t have time to take down the dressing but he was exquisitely tender over it.

I was taken to see one other patient but she wasn’t in her bed. The woman in the bed next to hers said that she had needed to leave to check on her family at home and would be coming back to the hospital tomorrow. I didn’t have time to even ask what her problem was.

So we had a plan. We would transfer the three stretcher patients plus the 30 year old man with the isolated gunshot to the hand. He would be number 4 on the plane today because his injury was fresh and most, if not all of the function of his hand was intact; of all the walking wounded he could benefit the most from having early treatment in Bangui. After the plane was in the air, I would wash-out and examine the thumb amputation/forearm fracture in the OR with the local Carnot staff while the others unpacked our supplies and equipment. Then we would tour the hospital and facilities as a team to decide what operations we wanted to do here the next day and if we would try to evacuate anyone else to Bangui on a second flight.

It was still a frenetic job making sure everyone had working IVs, re-checking vital signs, making sure the patients understood what was happening, identifying one family member or friend to accompany each patient to Bangui, loading the patients into the Landcruisers and then driving back to the airfield where every bump on the dirt road was obviously painful for the patients, but we rolled up to the plane right at 3. By twenty after, the plane was in the air for Bangui.

The rest of the afternoon went as planned and I was feeling pretty good about the day’s work until a little before 6PM. My last task of the day was to check on Mr. Open Humerus fracture with a non-viable hand from arterial injury. When I saw him initially he was still under the effects of the ketamine anesthesia they had used for his initial operation to control the bleeding. I wanted to see for myself that his mental status had returned to normal and confirm that he didn’t have a head injury.

As I approached his bed it was obvious that something was wrong. Our anesthetist C. was already by the bedside with an oximeter and blood pressure cuff. The patient’s breathing was rapid and shallow, his 02 sat a borderline 90%. His blood pressure was OK but his pulse was too fast. Between breaths he said “Ca marche pas”…”I’m not well”. I examined his chest and felt air bubbles under his skin on the side of his injured arm. It’s called crepitus and feels like a stack of crepe paper. I checked again for a chest wound but there was none. But he definitely had a chest wound somewhere, likely with two bullet entrance wounds in the upper arm but only one exiting the arm, the other moving directly into the chest through the armpit. Either an x-ray or careful bedside exam would have revealed this earlier but the situation right now is that he needs a chest tube ASAP.

We were supposed to be back at the MSF compound no later than 6PM, about the time it turns dark here. As we hurried over to the store room to get a chest tube kit, our OR nurse T. calls the Carnot MSF project chief to get permission to stay a little longer. It was getting darker by the minute and Mr. Open Humerus was still in the dark corner of the building without electricity. While I put in his chest tube by head-lamp light, C. began setting up the oxygen extractor and arranging for the nurses to move him to one of the few buildings in the complex that has electricity at night. When the tube went in, we were rewarded with a small rush of air, 250 cc of blood and immediate improvement in his breathing followed by improvement in his 02 sat.

We made it back to the MSF compound by 7PM for the nightly security briefing, then dinner, then finished with a team discussion about the plan for the next day.  We have arranged for a plane in the morning to transfer Mr. Open Humerus (who is now Mr. Chest Tube/Open Humerus) to Bangui.

We aren’t in complete agreement about how much surgery we should do here and how much we should transfer to Bangui. One issue is how much we can safely compromise our peri-operative standards while operating here and be sure we will do more good than harm. My two teammates have slightly different views on the subject and I understand them both. For now we are planning on the transfer and a pair of simple things in the OR tomorrow to see how it works.

Welcome to Carnot.